SLR - August 2013 - Dong M. Kim
Endara, M, Masden D, Goldstein J, et al. The Role of Chronic and Perioperative Glucose Management in High Risk Surgical Closures: A Case for Tighter Glycemic Control, Plastic and Recon Surg. 2013, advance online article
Scientific Literature Review
Reviewed by: Dong M Kim, DPM
Residency Program: Inova Fairfax Hospital
Podiatric Relevance: It is generally accepted that glycemic control is a key aspect in successful wound healing. Poor glucose control has been associated with delayed healing, increased rates of wound infection and mortality. With the prevalence of people in the United States suffering from diabetes along with the subset of those people developing foot ulcers, proper and prompt treatment is paramount in limb salvage. Incision and debridement is the first step in combating limb threatening infections. However, just as important to limb salvage is proper timing of definitive closure. The purpose of this study was to determine the influence that glycemic control had on complication rates in high-risk patients undergoing surgeries, specifically aimed at wound closure.
Methods: Seventy-nine patients who met the criteria for surgical closure including adequate blood flow and freedom from infection were retrospectively reviewed. Charts were reviewed for glucose measurements taken five days before and after surgical closure. HbA1c levels were obtained during their hospital stays, as well as within four months of closure attempt. Glucose swings were calculated by subtracting patients’ lowest to highest glucose measurements. Primary outcome measures were rates of dehiscence, infection, and re-operation that occurred within the perioperative period defined as occurring within 30 days of surgical closure. Patients were then classified into a hyperglycemic group if they measured above 200 in the preoperative, postoperative, or perioperative period. Analysis was also performed for those with a full set of glucose measurements versus those without a complete data set available. For association of chronic glycemic control, three cut-offs for HBA1c were created: 6.0, 6.5, and 7.0.
Results: Data was collected on 81 patients, but two were lost to follow up. The majority of the closures were lower extremity. Most had diabetes, hypertension, and peripheral vascular disease. When looking at preoperative, postoperative, and perioperative settings, patients with hyperglycemia dehisced at a statistically significant higher rate than patients without hyperglycemia. The difference in reoperation rates and infection rates were not statistically significant. It was also found that those with greater swings in glucose control had statistically significant higher rates of dehiscence and re-operation than those who did not. The difference in infection rates were not statistically significant. As HBA1c values increased, there was a strong association with dehiscence.
Conclusion: According to the study, only perioperative hyperglycemia and elevated HBA1c seemed to be significantly associated with increased rates of dehiscence. However, HBA1c levels may not be great predictors for perioperative glucose control. Nevertheless, the cutoff glucose number of 200 and HBA1c of 6.5 may act has guidelines for physicians to shoot for in the goal for limb salvage in this high-risk population.